Pregorexia: a Psychotherapy Strategy for Eating Disorders in Pregnant Women

Pregorexia refers to an eating disorder observed in pregnant women characterized by the adoption of extreme dieting and workout regime during pregnancy meant to ward off weight gain and keep body shape under control. Psychological factors such as a distortion of how one perceives their own body, concerns about visible signs of pregnancy, and fear of gaining weight have been identified as some of the underlying causes of pregorexia. This condition may have detrimental effects, such as stunted fetal growth, spontaneous miscarriage, and development of anemia by the pregnant woman.

INTRODUCTION

Pregorexia is an eating disorder that emerges in women during pregnancy and the postpartum period. It is characterized by dietary restrictions, compensatory behaviors (such as self-induced vomiting, use of diuretics or laxatives), and excessive exercising before and after the birth of the child, all aimed at controlling weight and body shape [1]. Despite being a serious condition with long-term consequences for both the mother and her child, pregorexia poses several challenges regarding diagnosis and effective psychotherapy strategies [2]. In the ICD-11 and DSM-5, pregorexia is classified as “Unspecified feeding and eating disorder/Other feeding or eating disorder”¹ [3].

There is no consensus on the prevalence of pregorexia, ranging from 0.6% to 27.8% according to different studies [4]. Incorrect and delayed diagnosis of pregorexia can have adverse effects on a pregnancy, leading to impaired fetal growth and physical health deterioration in pregnant women. Dehydration and cardiovascular dysfunction are among the risks faced by pregnant women with pregorexia. Additionally, the consequences of pregorexia include placental insufficiency resulting in missed abortion and miscarriages, premature birth, small-for-gestational-age baby, as well as infant conditions, such as omphalocele and gastroschisis, neural tube defects, including anencephaly [5].

PLACE OF PREGOREXIA AMONG EATING DISORDERS

Due to the limited number of epidemiological studies on pregorexia, it is challenging to accurately determine its incidence. However, it has been observed that approximately 25% of pregnant women exhibit some signs of eating disorders, with their prevalence rate ranging from 5% to 7.5% among them [6].

Several risk factors increase the likelihood of developing pregorexia during the pre- and postnatal periods [7]. These include:

• a history of previous episodes of eating disorders;
• other current psychiatric disorders such as depressive episodes, anxiety disorder, or obsessive-compulsive disorder;
• experience of sexual or physical abuse in the past;
• obsession with body image (body dysmorphic disorders);
• unintended pregnancy;
• addictions; and
• lack of community support during pregnancy.

Apart from individual psychological and physiological risk factors, it is crucial to acknowledge the impact the environment can have on pregnant women. The immediate and extended environments, along with what is offered in the media, convey the idea that one needs to constantly watch one’s body weight and shape, as well as distrust their own internal sensations and experiences. The images in the media put relentless pressure on women to try to look “physically attractive” and conform to set beauty standards. In the postnatal period, pregorexia can be triggered by societal pressure on women to swiftly return to their “pre-pregnancy” body shape, while simultaneously breastfeeding and prioritizing the needs of their infant. The conflicting expectations of being the perfect mother and the perfect woman contribute to chronic emotional stress, which pushes some women to resort to dietary restrictions, cleansing practices, and compulsive exercising as means to self-regulate their emotions.

PSYCHOTHERAPY APPROACHES TO PREGOREXIA

Given the limited research on the specific psychotherapeutic approaches to pregorexia as a distinct eating disorder, the American Psychiatric Association Practice Guideline for the Treatment of Patients with Eating Disorders recommends to employ cognitive-behavioral therapy (CBT-AN, CBT-E). Additionally, in our practice, my colleagues and I also use acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), expressive therapy (art therapy), and family/partner counseling [8].

Based on personal experiences and those of my colleagues in the psychotherapy of patients with pregorexia, the following therapeutic targets have been identified:

• Body image, which includes addressing interoceptive awareness, emotional, cognitive, and behavioral aspects, as well as the perception of one’s body in space. The rapid and often unpredictable changes in body image during pregnancy and the postpartum period can cause significant emotional distress [9, 10]. This distress may push women to resort to dietary restrictions, compensatory behaviors, and excessive exercising;
• Gestational dominance: particularly relevant in cases of hypogestognostic or anxiety-depressive types [11];
• Dysfunctional attitudes toward lifestyle during pregnancy and the postnatal period;
• Eating behavior parameters encompassing aspects such as food restriction, compulsive body-checking behaviors, compensatory behaviors (such as self-induced vomiting, use of diuretics or laxatives, and excessive exercising aimed at “burning of” every calorie they intake);
• The influence of social connections and emotional factors in interpersonal relations, including relationships with the healthcare professionals involved in the care of women during and after pregnancy.

To facilitate the diagnosis of eating disorders in pregnant women and in the postnatal period, the following questionnaires may be utilized: Body Image Questionnaire, EAT-26 (Eating Attitudes Test-26), Eating Behavior Rating Scale [12, 13, 14].

Considering time constraints and the health risks involved for both the pregnant woman and the fetus, it is advisable to establish goals and objectives for psychotherapy that prioritize behavioral changes (renouncing dietary restrictions, cleansing practices, calorie counting, and expanding the variety and quantity of food consumed).

At the beginning of psychotherapy, it is recommended [15] to maintain a food diary with a focus on capturing the emotional state before and after eating, monitoring sensations of hunger and satiety, documenting episodes of cleansing behaviors and compulsive weighing, and analyzing triggers that evoke negative emotions. Keeping a food diary helps clients enhance their awareness of eating disorders and the events that trigger them. It also helps to identify and categorize eating-related situations as challenging or manageable. Additional tools used in the psychotherapy of pregorexia include training in bodily relaxation techniques and mindfulness practices to reduce anxiety and prevent episodes of eating disorders. These interventions are commonly employed in the psychotherapy of other eating disorders and are deemed suitable for pregorexia psychotherapy [16–20].

Alongside the focus on behavioral changes, acceptance and commitment therapy incorporates work on the value system [21, 22].

Target values are identified, such as physical health and motherhood, and, subsequently, goals and objectives are established based on these values. This approach aims to increase value-oriented and motivation-driven patterns of behavior.

CONCLUSIONS AND RECOMMENDATIONS

• Psychoprophylactic measures are needed in pregnant women with a history of eating disorders and related episodes.
• Effective management of patients with pregorexia requires collaboration between psychologists, nutritionists, and gynecologists.
• In cases where eating disorders are suspected during pregnancy and/or the postnatal period, a comprehensive assessment of the woman’s condition is crucial. This assessment should encompass factors such as the history of weight and height fluctuations, patterns of eating behavior (e.g., food and calorie restriction, skipping of meals, compulsive overeating, chewing and spitting, regurgitation), compensatory behaviors, and other weight management strategies (e.g., excessive exercising, cleansing behaviors like self-induced vomiting, misuse of diuretics and laxatives, use of weight loss medications). Additionally, it is also necessary to assess the significance placed on nutrition, weight, and body shape, the presence or absence of a history of eating disorders and response to previous psychotherapy, as well as the presence of any secondary socio-psychological disorders linked to eating behavior and appearance.
• It is crucial to acknowledge that women with pregorexia may deliberately conceal their symptoms or may not be fully aware of the severity of the disorder and the potential harm it poses to their own health, as well as the health of their fetus.

¹ International Classification of Diseases 11^th Revision. The global standard for diagnostic health information. Available from: https://icd.who.int/browse11/l-m/ru.

1. Tuncer E, Bayindir GA, Keser A. The importance of pregorexia awareness. Clinical and Experimental Health Sciences. 2020;10(3):186–190.
2. Mandera A, Pawlikowska A, Szuster EM, Całkosiński A, Kostrzewska P, Majewski M. The pregorexia — anorexia during the pregnancy. Journal of Education, Health and Sport. 2019;9(5):137–144.
3. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington VA: American Psychiatric Association; c2013.
4. Easter A, Bye A, Taborelli E, Corfield F, Schmidt U, Treasure J, Micali N. Recognising the symptoms: how common are eating disorders in pregnancy? European Eating Disorders Review. 2013;21(4):340-344. doi: 10.1002/erv.2229.
5. Smink FR, van Hoeken D, Hoek HW. Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports. 2012;14(4):406–414. doi: 10.1007/s11920-012-0282-y.
6. Sebastiani G, Andreu-Fernández V, Herranz Barbero A, Aldecoa-Bilbao V, Miracle X, Meler Barrabes E, et al. Eating disorders during gestation: implications for mother’s health, fetal outcomes, and epigenetic changes. Frontiers in Pediatrics. 2020;8:587. doi: 10.3389/fped.2020.00587.
7. Mathieu J. What is pregorexia? Journal of the American Dietetic Association. 2009;109(6):976–979. doi: 10.1016/j.jada.2009.04.021.
8. Crone C, Fochtmann LJ, Attia E, Boland R, Escobar J, Fornari V, Golden N, Guarda A, Jackson-Triche M, Manzo L, Mascolo M, Pierce K, Riddle M, Seritan A, Uniacke B, Zucker N, Yager J, Craig TJ, Hong SH, Medicus J. The American Psychiatric Association Practice Guideline for the Treatment of Patients with eating disorders. American Journal of Psychiatry. 2023;180(2):167–171. doi: 10.1176/appi.ajp.23180001.
9. Ross LE, McLean LM. Anxiety disorders during pregnancy and the postpartum period: a systematic review. The Journal of Clinical Psychiatry. 2006;67(8):1285–1298. doi: 10.4088/jcp.v67n0818.
10. Goodman JH, Chenausky KL, Freeman MP. Anxiety disorders during pregnancy: a systematic review. The Journal of Clinical Psychiatry. 2014;75(10):e1153-84. doi: 10.4088/JCP.14r09035.
11. Skritskaya TV. Value orientations of women during pregnancy [dissertation]. Novosibirsk: Novosibirsk State Pedagogical University; 2002. p. 162. Russian.
12. Ilchik OA, Sivukha SV, Skugarevsky OA, Suikhi S. Russian-language adaptation of the “Eating Behavior Assessment Scale” methodology. Psychiatry, Psychotherapy and Clinical Psychology. 2011;1:39–50. Russian.
13. Золотарева А.А. Psychometric properties of the Body Image Assessment Scale (approbation on the Russian sample). Experimental psychology. 2023;16(1):201–210. doi: 10.17759/exppsy.2023160112. Russian.
14. Shah MW, Ahmad T, Khan M, Sun G. Global research trends, top-100 most cited studies, and network visualization of eating and feeding disorders research from 1900–2020: a historical bibliometric analysis. Electronic Journal of General Medicine. 2022; 19(3):em368. doi: 10.29333/ejgm/11839.
15. Fairburn CG, Cooper Z, Doll HA, O’Connor ME, Bohn K, Hawker DM, Wales JA, Palmer RL. Transdiagnostic cognitive-behavioral therapy for patients with eating disorders: a two-site trial with 60-week follow-up. American Journal of Psychiatry. 2009;166(3):311–319. doi: 10.1176/appi.ajp.2008.08040608.
16. Alberts HJ, Thewissen R, Raes L. Dealing with problematic eating behaviour. The effects of a mindfulness-based intervention on eating behaviour, food cravings, dichotomous thinking and body image concern. Appetite. 2012;58(3):847–851. doi: 10.1016/j.appet.2012.01.009.
17. Arch JJ, Craske MG. Mechanisms of mindfulness: emotion regulation following a focused breathing induction. Behaviour Research and Therapy. 2006;44(12):1849–1858. doi: 10.1016/j.brat.2005.12.007.
18. Brown KW, Ryan RM. The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology. 2003;84(4):822–848. doi: 10.1037/0022-3514.84.4.822.
19. Dalen J, Smith BW, Shelley BM, Sloan AL, Leahigh L, Begay D. Pilot study: Mindful Eating and Living (MEAL): weight, eating behavior, and psychological outcomes associated with a mindfulness-based intervention for people with obesity. Complementary Therapies in Medicine. 2010 Dec;18(6):260–264. doi: 10.1016/j.ctim.2010.09.008.
20. Brooker JE, Webber L, Julian J. et al. Mindfulness-based training shows promise in assisting staff to reduce their use of restrictive interventions in residential services. Mindfulness. 2014; 5(5):598–603. doi: 10.1007/s12671-014-0306-2.
21. Sandoz EK,Wilson KG, DuFrene T. Acceptance and commitment therapy for eating disorders: a process-focused guide to treating anorexia and bulimia. New Harbinger Publications; c2011.
22. Mervin PM, Tsuker NL, Wilson KG. ACT for Anorexia Nervosa. A Guide for Clinicians. Saint Petersburg: LLC Dialectica; c2022. Russian.